Primary Health Care remains the Best Tool to Achieve “Health for All” -- Interim Position of the People’s Health Movement

In its renewed commitment to PHC, in 2008, PHM vies to address the obstacles that have blocked PHC's implementation so far and is furthermore committed to incorporate into it the new challenges that have emerged since 1978.

PHM is committed to promote the still unshaken basic principles of the Alma Ata Declaration --way beyond its original eight technical components.

PHM insists that PHC is to be embedded in the social and political processes in each specific context where it is applied. For that, it must:

• be neither limited to just the primary level of care, nor be considered merely as a "basic" package of care for the poor, but include public health interventions, health promotion and a working referral system to secondary and tertiary levels of care;
• be financed through public sources, so as to ensure universal and equitable access;
• address the socio-economic injustice underlying a system of health care that does not provide equitable access and care according to need;
  resolutely address the social, political, economic and environmental determinants of health and not just be limited to health care;
  address the issues of global warming, the current international economic order and the militarization the latter has brought about.
• empower communities, especially, the most disadvantaged, so that they can act as protagonists in improving their health and their livelihoods;
  use technology in a manner that is sensitive to local needs and contexts;
  combine traditional and modern medicine to maximize benefits to patients; and
• embed policies and interventions in the human rights framework, i.e., recognising and supporting the role of beneficiaries as claim holders with an internationally sanctioned right to hold to account duty bearers in bringing about needed changes in the provision of health care services.

PHM takes the new challenges that have emerged in the last 30 years, as challenges that must be incorporated in a renewed vision for PHC. In this context, PHM strongly believes that:

• Neoliberal globalisation presents us with new threats to health such as, among other, an increase in trade in unhealthy commodities, international trade agreements that are promoting the penetration of transnational corporations into the health sector, patent rights being used against the dire health needs of poor people, and unfair rules in the international trade of agricultural products that devastate the livelihood and health of poor peasants. All of them seriously undermine the ability of poor countries to adequately support PHC systems. Global inequities also result in poor countries being left with too few resources to sustain funding for health systems overall, thereby becoming reliant on external sources of funding. PHM posits that the negative aspects of globalization are the major obstacle to Health For All. Outside the present neoliberal framework, certain aspects of globalization can and should be used to address the social, economic and political determinants of health.
• After over 25 years, selective, vertical health care programs remain dominant, not only fragmenting wider health systems, but also drawing away scarce resources, treating patients as passive recipients of care and ignoring the ever-present social, economic and political determinants of health. PHM recognizes that, while there may be a need for focused programmes, the same need to be integrated into a comprehensive PHC approach.
• The planning and execution of PHC activities must be genuinely community-driven and community-centered.
  Both in light of the looming health manpower crisis, and as a core PHC principle, there must be a renewal of the role of community health workers to not only extend coverage at the local level, but also to give them a concrete role as social mobilizers in the right to health-based empowerment of communities, particularly in relation to the social determinants of health. PHM thus strongly emphasizes the training of health workers, not only in clinical and preventive health skills, but also in skills that make them effective agents of social change.
• Significant investments in PHC do bring about important changes --as the example of Brazil has demonstrated. PHM advocates for similar initiatives being actively pursued by countries across the globe.
• For a good PHC policy to succeed and to make a real difference in access and in equity, it must have sufficient resources specifically allocated to it. PHM thus lobbies states to invest more in public health, particularly in PHC. At the same time, PHM strongly feels that WHO should lead this effort: it simply cannot consider itself as just a technical agency.
• Global public private partnerships (PPPs) are seen as a way to bring new financial resources to address global health challenges. However, in reality, they have further reinforced selective programs by focusing on non-sustainable, techno-centric solutions to single issues, and are not addressing the social determinants of health or many of the burning needs of health systems to deliver such services. PPPs need to be seriously reoriented towards more horizontally-integrated, sector-wide approaches that have the explicit commitment to strengthen health systems, to respond to local needs and to build new alliances with civil society, people's organisations and social movements --thus reasserting the central place of democratic, participatory decision-making in all health services. PHM purports that there is a need to carry out a proper audit of existing global PPPs, in order to arrive at the basic principles and rules that such PPPs need to abide by, among other making them build upon existing public systems and embedding them in a PHC structure.
• The last thirty years have seen increasing privatisation and commercialisation of health systems across the world. The new market economy in health has undermined public sector health systems and has eroded the ethical standards among health workers, as well as the trust between communities and the health system. The result has been exacerbated inequity and growing disparities in access to health care. PHM thus thinks that there is a profound need in most countries to strengthen the public health sector and the ‘public ethic' of service provision and that the private medical sector needs to be regulated as a matter of priority.
• PHC in 2008 and beyond must address the critical problems of the global health workers' labour market and must ensure an adequate human resource base for the health systems of all countries --including compensating poor countries for the losses suffered by their health systems as a consequence of migration of health humanpower.
• Intellectual property issues are increasingly used against the interests of poor countries. The development of technology for the treatment of diseases is oligopolistic and ignores the research needs for diseases of poverty.. Moreover, many useful technologies already available in 1978 are still unavailable to most people. Intellectual property rules cannot be allowed to continue to make new life-saving medications unavailable and unaffordable to the people who need them the most. PHC requires universal access to essential medicines, with most of them made available as generics. PHM will confront patent regimes that are primarily market-oriented; it will support countries to make full use of the flexibilities in TRIPS that make necessary drugs available to all who need them.
• The institutions involved in PHC will need to change their focus. But it is not a time to blame; it is a time to move forward.

Three decades have passed since Alma Ata and the situation is worse than what it was in 1978. Our ability to support human health is now at greater risk from an unjust and unsustainable process of development; inequities have increased between and within countries; access to food, education, water, shelter, sanitation and employment are still greatly inadequate for many; the challenges of globalization, poverty, gender inequity and social exclusion continue; both communicable and non-communicable disease epidemics challenge health systems already stretched to the limit; and war, violence and conflict abound.

Today, 30 years after Alma Ata, PHM looks at WHO to provide not only the technical, but also the moral and political leadership in this entire process. It has to reclaim its legitimate position as the global leader in promoting policies that lead to a world with healthy populations. Specifically, PHM expects WHO to support member countries to adopt policies that promote PHC as an integral part of their national policies. This support is not just to be given in the area of health systems development, but also in promoting policies that more resolutely address the issues related to the social determinants of health. WHO should also take the lead in promoting alternate models of research that promote the development of health products that address the critical needs of people in developing countries.

For PHM, while THE PRIMARY HEALTH CARE OF 2008 AND BEYOND reiterates the core principles of Alma Ata, it must, in addition, address these new challenges at local, national, regional and global levels. This is PHM's commitment, i.e., to put the health of marginalised groups at the center of its commitment to ‘Health for All Now' --a commitment already espoused by the PHM in 2000 as the core principle of its People's Health Charter.

(PHM is working on a more elaborate position to be released later this year; it includes a critical analysis of WHO's shortcomings in defending the principles of Alma Ata over the years and how WHO is profiling its role to support PHC in 2008 and beyond. It also addresses difficult questions such as whether WHO and member states are ever going to bring health to poor and marginalized groups in society ---and if not, who will and who should PHM be engaging more closely with.)